Download Classic HMO 20/30 100/day Select HMO Network HMOB

This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform
laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be
required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the
California Department of Insurance and the California Department of Managed Health Care.
Anthem Blue Cross Select HMO benefits are covered only when services are provided or coordinated by the primary care physician
and authorized by the participating medical group or independent practice association (IPA), except services provided under the
“ReadyAccess” program, OB/GYN services received within the member’s medical group/IPA, and services for all mental and
nervous disorders, and substance abuse. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy.
This plan has a special network including a limited number of Physicians, Independent Practice Associations (IPAs) and Medical
Groups and a limited Service Area which includes only certain counties and cities as described in Anthem’s Provider Directory.
The member must live and/or work in this limited Service Area to enroll in the Select HMO Plan.
HMO Benefits
Classic HMO 20/30 100/day
Select HMO Network
Annual copay maximum: Individual $1,500; Family $3,000
The following copay does not apply to the annual copay maximum:
for infertility services
Covered Services
Per Member Copay
Inpatient Medical Services
Semi-private room or private room if medically necessary;
meals & special diets; services & supplies including:
— Special care units
— Operating room & special treatment rooms
— Nursing care
— Drugs, medications & oxygen administered in the hospital
Blood & blood products
$100/day
No copay
Outpatient Medical Services
(Services received in a hospital, other than emergency room services,
or in any facility that is affiliated with a hospital)
Outpatient surgery & supplies
Diagnostic X-ray & laboratory procedures
— CT or CAT scan, MRI or nuclear cardiac scan
— PET scan
— All other X-ray & laboratory tests (including mammograms and ultrasounds)
Radiation therapy, chemotherapy & hemodialysis treatment
Short-term Physical, Occupational, or Speech Therapy
(limited to a 60-day period of care after an illness or injury;
additional visits available when approved by the medical group)
Ambulatory Surgical Center
Outpatient surgery & supplies
No copay
$100/test
$100/test
No copay
No copay
No copay
No copay
Skilled Nursing Facility
(limited to 100 days/calendar year)
All necessary services & supplies (excluding take-home drugs)
No copay
Hospice Care (Inpatient or outpatient services for members; family bereavement services)
Home Health Care
Home visits when ordered by primary care physician
(limited to 100 visits/calendar year; one visit by a
home health aide equals four hours or less)
No copay
No copay
Physician Medical Services
Office & home visits
Hospital visits
Skilled nursing facility visits
Specialists & consultants
anthem.com/ca
$20/visit
No copay
No copay
$30/visit
Anthem Blue Cross
(P-NP)
LH2083-SH
Effective 1/2011
Printed 9/27/2010
Covered Services
Per Member Copay
Short-Term Physical, Occupational, or Speech Therapy, or
Chiropractic Care when Ordered by the Primary Care Physician
(limited to a 60-day period of care after an illness or injury; additional
visits available when approved by the medical group)
$20/visit
Acupuncture
$20/visit
Surgical Services
Surgeon & surgical assistant
Anesthesiologist or anesthetist
No copay
No copay
General Medical Services
(when performed in non-hospital-based facility)
Diagnostic X-ray & laboratory procedures
— CT or CAT scan, MRI or nuclear cardiac scan
— PET scan
— All other X-ray & laboratory tests (including mammograms,
pap smears, & prostate cancer screening)
Radiation therapy, chemotherapy & hemodialysis treatment
Other Medical Services
Prosthetic devices
Durable medical equipment including hearing aids
(hearing aids benefit available for one hearing aid per ear every three years)
Preventive Care Services
Preventive Care Services that meet the requirements of federal and state law,
including certain screenings, immunizations and physician visits
Complete physical exams & periodic routine
checkups when ordered by the primary care physician
Well-baby & well-child care
Well-woman exams
Hearing exams
Vision exams (vision screening from primary care physician
covers evaluation only; diagnostic & treatment programs,
including refractions, from an optometrist or ophthalmologist
must be authorized by the primary care physician)
$100/test
$100/test
No copay
No copay
No copay
20% of charges
No copay
No copay
No copay
No copay
No copay
Health Education and Wellness Programs
Specified immunizations
Allergy testing & treatment (including serums)
Medical social services
Selected health education programs
No copay
$20/exam
No copay
No copay
Emergency Care
In Area (within 20 miles of medical group) and Out of Area
Physician & medical services
Outpatient hospital emergency room services
Inpatient hospital services
No copay
$100/visit (waived if admitted)
$100/day
Ambulance Services
Ground or air ambulance transportation when medically
necessary, including medical services & supplies
No copay
Covered Services
Per Member Copay
Pregnancy and Maternity Care
Office Visits
Prenatal & postnatal care
Complications of pregnancy or therapeutic abortions
Normal Delivery or Cesarean Section, including:
Inpatient hospital & ancillary services,
including routine nursery care
Physician services (inpatient only)
Complication of Pregnancy or Therapeutic Abortion, including:
Inpatient hospital & ancillary services
Outpatient hospital services
Physician services (inpatient only)
$100/day
No copay
No copay
Elective Abortions (including prescription drug for abortion [mifepristone])
$150
Genetic Testing of Fetus
No copay
Family Planning Services
Infertility studies & tests
Tubal ligation
Vasectomy
Counseling & consultation
50% of covered expense1
$150
$50
No copay
Organ and Tissue Transplant
Inpatient Care
Physician office visits
Specialist and consultant office visits
$100/day
$20/visit
$30/visit
$20/visit
$20/visit
$100/day
No copay
Mental or Nervous Disorders and Substance Abuse
Inpatient Care
Facility-based care (pre-authorization required)
Physician hospital visits
Outpatient Care
Facility-based care (pre-authorization required)
Outpatient physician visits (pre-service review required after the 12th visit)
No copay
$20/visit
Smoking Cessation Program
No copay
$100/day
No copay
1 Not applicable to the annual copay maximum
This Summary of Benefits is a brief review of benefits. Once enrolled, members will receive the Combined Evidence of Coverage
and Disclosure Form, which explains the exclusions and limitations, as well as the full range of covered services of the plan,
in detail.
Classic HMO — Exclusions and Limitations
Care Not Approved. Care from a health care provider without the OK of primary care doctor,
except for emergency services or urgent care.
Care Not Covered. Services before the member was on the plan, or after coverage ended.
Care Not Listed. Services not listed as being covered by this plan.
Care Not Needed. Any services or supplies that are not medically necessary.
Crime or Nuclear Energy. Any health problem caused: (1) while committing or trying to commit a
felony, as long as any injuries are not a result of a medical condition or an act of domestic violence;
or (2) by nuclear energy, when the government can pay for treatment.
Experimental or Investigative. Any experimental or investigative procedure or medication.
But, if member is denied benefits because it is determined that the requested treatment is
experimental or investigative, the member may ask that the denial be reviewed by an external
independent medical review organization, as described in the Evidence of Coverage (EOC).
Government Treatment. Any services the member actually received that were given by a local,
state or federal government agency, except when this plan’s benefits, must be provided by law.
We will not cover payment for these services if the member is not required to pay for them or they
are given to the member for free.
Services Given by Providers Who Are Not With Anthem Blue Cross HMO. We will not
cover these services unless primary care doctor refers the member, except for emergencies
or urgent care.
Services Not Needing Payment. Services the member is not required to pay for or are given
to the member at no charge, except services the member got at a charitable research hospital
(not with the government). This hospital must:
1. Be known throughout the world as devoted to medical research.
2. Have at least 10% of its yearly budget spent on research not directly related to patient care.
3. Have 1/3 of its income from donations or grants (not gifts or payments for patient care).
Custodial Care or Rest Cures. Room and board charges for a hospital stay mostly for a change
of scene or to make the member feel good. Services given by a rest home, a home for the aged,
or any place like that.
Dental Services or Supplies. Dentures, bridges, crowns, caps, or dental prostheses, dental
implants, dental services, tooth extraction, or treatment to the teeth or gums. Cosmetic dental
surgery or other dental services for beauty purposes.
Diabetic Supplies. Prescription and non-prescription diabetic supplies, except as specified as
covered in the EOC.
Eye Exercises or Services and Supplies for Correcting Vision. Optometry services, eye
exercises, and orthoptics, except for eye exams to find out if the member’s vision needs to be
corrected. Eyeglasses or contact lenses are not covered. Contact lens fitting is not covered.
Eye Surgery for Refractive Defects. Any eye surgery just for correcting vision (like
nearsightedness and/or astigmatism). Contact lenses and eyeglasses needed after this surgery.
Growth Hormones. Growth hormone treatment.
Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this
plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas
and dietary supplements that can be purchased over the counter, which by law do not require either
a written prescription or dispensing by a licensed pharmacist.
Health Club Membership. Health club memberships, exercise equipment, charges from a physical
fitness instructor or personal trainer, or any other charges for activities, equipment, or facilities used
for developing or maintaining physical fitness, even if ordered by a doctor. This exclusion also
applies to health spas.
Hearing Aids. Hearing aids or services for fitting or making a hearing aid, except as specified as
covered in the EOC.
Immunizations. Immunizations needed to travel outside the USA.
4. Accept patients who are not able to pay.
Infertility Treatment. Any infertility treatment including artificial insemination or in vitro fertilization,
sperm bank, and any related laboratory tests.
5. Serve patients with conditions directly related to the hospital’s research (at least 2/3 of
their patients).
Lifestyle Programs. Programs to help member change how one lives, like fitness clubs, or dieting
programs. This does not apply to cardiac rehabilitation programs approved by the medical group.
Work-Related. Care for health problems that are work-related if such health problems are or can be
covered by workers’ compensation, an employer’s liability law, or a similar law. We will provide care
for a work-related health problem, but, we have the right to be paid back for that care. See “Third
Party Liability” below.
Mental or nervous disorders. Academic or educational testing, counseling. Remedying an
academic or education problem, except as stated as covered in the EOC.
Acupressure. Acupressure, or massage to help pain, treat illness or promote health by putting
pressure to one or more areas of the body.
Orthopedic Shoes. Orthopedic shoes (except when joined to braces) or shoe inserts (except
custom molded orthotics). This does not apply to shoes and inserts designed to prevent or treat foot
complications due to diabetes.
Air Conditioners. Air purifiers, air conditioners, or humidifiers.
Birth Control Devices. Any devices needed for birth control which can be obtained without a
doctor’s prescription such as condoms.
Blood. Benefits are not provided for the collection, processing and storage of self-donated blood
unless it is specifically collected for a planned and covered surgical procedure.
Non-Prescription Drugs. Non-prescription, over-the-counter drugs or medicines.
Outpatient Drugs. Outpatient prescription drugs or medications including insulin.
Personal Care and Supplies. Services for personal care, such as: help in walking, bathing,
dressing, feeding, or preparing food. Any supplies for comfort, hygiene or beauty purposes.
Braces or Other Appliances or Services for straightening the teeth (orthodontic services).
Private Contracts. Services or supplies provided pursuant to a private contract between the
member and a provider, for which reimbursement under the Medicare program is prohibited,
as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act.
Chronic Pain Treatment. Treatment of frequent recurrences of pain, over a long period of time,
that is not related to an active medical condition currently being treated.
Routine Exams. Routine physical or psychological exams or tests asked for by a job or other
group, such as a school, camp, or sports program.
Clinical Trials. Services and supplies in connection with clinical trials, except as specified
as covered in the Evidence of Coverage (EOC).
Scalp hair prostheses. Scalp hair prostheses, including wigs or any form of hair replacement.
Consultations given by telephone or fax.
Commercial weight loss programs. Weight loss programs, whether or not they are pursued under
medical or doctor supervision, unless specifically listed as covered in this plan.
This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers,
Jenny Craig, LA Weight Loss) and fasting programs.
This exclusion does not apply to medically necessary treatments for morbid obesity or for treatment
of anorexia nervosa or bulimia nervosa.
Cosmetic Surgery. Surgery or other services done only to make the member: look beautiful;
to improve appearance; or to change or reshape normal parts or tissues of the body. This does not
apply to reconstructive surgery the member might need to: get back the use of a body part; have for
breast reconstruction after a mastectomy; correct or repair a deformity caused by birth defects,
abnormal development, injury or illness in order to improve function, symptomatology or create a
normal appearance. Cosmetic surgery does not become reconstructive because of psychological or
psychiatric reasons.
Sex Change. Sex change surgery or treatments.
Sexual Problems. Treatment of any sexual problems unless due to a medical problem,
physical defect, or disease.
Sterilization Reversal. Surgery done to reverse a sterilization.
Surrogate Mother Services. For any services or supplies provided to a person not covered under
the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a
child by another woman for an infertile couple).
Third Party Liability – Anthem Blue Cross is entitled to reimbursement of benefits paid if the
member recovers damages from a legally liable third party.
Coordination of Benefits – The benefits of this plan may be reduced if the member has any other
group health or dental coverage so that the services received from all group coverages do not
exceed 100% of the covered expense.
Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee
of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance
Companies, Inc. The Blue Cross name and symbol are registered marks of the
Blue Cross Association.